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STATE ID NUMBER <br /> CONTAINER CONSTRUCTION <br /> E. 1 1 `01 RUBBER LINED f 1 02 ALKTO LINING 1 ) 03 EPDXY LINING 1 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> 1 07 UILIUED f 1 OB UNKNOW(( 1 1 09 OTHER: <br /> F. 1 1 01 POLYETHLE14E WRAP 1 1 02 VINYL WRAPPING l 1 03 CATHODIC PROTECTION 1 1 04 UNKNOWN X1 05 NONE <br /> 1 1 06 TAR OR ASPHALT 1 , 09 OTHER: <br /> VI PIPING _ <br /> IA. ABOVEGROUND PIPINGS ( 1 01 DOUBLE—WALLED PIPE ( 1 02 CONCRETE—LINED TRENCH 1 1 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( 1 04 PRESSURE 1 1 05 SUCTION 1 ) 06 UNKNOIIH ( ) 07 NONE <br /> S. UIDERGROUIID PIPING% ( 1 01 DOUBLE—WALLED PIPE 1 ) 02 CONCRETE—LINED TRENCH 1 ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOXIESI y(j 04 PRESSURE 1 ) OS SUCTION 1 1 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> 1 1 01 VISUAL Q4 02 STOCK INVENTORY 1 1 04 VAPOR SNIFF WELLS 1 I IS SENSOR INSTRUMENT <br /> 1 1 06 GROU01 WATER MONITORING WELLS 1 1 07 PRESSURE TEST l 1 09 NONE (Xl 10 OTHER- 1h4A <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV•F YOU AAE NOT RE4VIRE0 TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CASK (If KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> 11 01 O 02 1 1 11 I r I l I I I l I I I I I <br /> I ) 01 l 1 02 1 1 03 <br /> 1 1 01 1 , 02 ( 1 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 1 1 01 1 1 02 ( 1 03 <br /> 1 ) 01 ( 1 02 ( ) 03 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> 1 ) 01 1 ) 02 1 1 03 <br /> 1 ) 01 ( 102 1 ) 031 I I I I I I I I I I I I <br /> 11 01 1 ) 02 1 1 03 <br /> ( <br /> L <br /> 1 01 1 , 02 1 ) 03 <br /> ' 101 ' ' 02_ t ,o3 ( IIIIIIIIIIII <br /> �13 CO'ITAIHER LOCATED ON AN AGRICULTURAL FARM? 1 1 01 YES ( JL02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. <br /> CE� v SID)IAJ tE ) PHO E W�!E C DE <br /> env rrpw -P. � <br /> R .A — - --- <br /> FOCAL AGENCY USE 0 LY � - I <br /> �a0'tfi C.Tw TINS ♦1E.4Y f\ I [ITT ODC COUNTY CODE <br /> CONTwrT o= SON C� - PHO E WAR[ CODE <br /> -- 1- __ -- t -- --- - ---- 7a <br /> OAT[ O� VST (NSR ECTl ON MIN COMOLIANCC I[RMIT APIROVAL DAT[ TPANSACTIOM DATF LOCAL PERMIT ID ■ <br /> ( C1 .CS t , OI NO <br /> HSC04-071105 \ `" PAGE 2 <br />